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450 HIGHLAND AVE - BUILDING INSPECTION (4) • � l 5`-k© ct`g��o ttit%� r C The Commonwealth c> pltm�5'sach169&t9, Department of Public Safety Massachusetts State Buildin Building Permit Application for any Building ot1 t�Halit a fide-ror Two-Family Dwelling _ (Fhis Section For Official Use Only) CIO Building Permit Number: Date Applied: Building Official: SECTION 1:LOCATION(Please.indicate Block#and Lot#-for locations for which a street address is not available) t 450 Highland Ave .n No.and Street City/Town Zip Code Name of Building(if applicable) - - ` SECTION 2:.PROPOSED WORK Edition of MA State Code used If New Construction check here❑or check all that apply in the two rows below fL,.I�1 Existing Building L Repair❑ 1 Alteration IN I Addition❑ 1 Demolition ❑ (Please fill out and submit Appendix 1) 1— Change of Use ❑ 1 Change of Occupancy ❑ 1 Other ❑ Specify: Are building plans and/or construction documents being supplied as part of this permit application? Yes H No ❑ Is an Independent Structural Engineering Peer Review required? Yes ❑ No LX Brief Description of Proposed Work: Adding a Vision Center into an existing space inside the Walmart store SECTION.3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR. CHANGE IN USE OR OCCUPANCY - - Check here if an Existing Building Investigation and Evaluation is enclosed(See 780 CMR 34) ❑ Existing Use Group(s): Proposed Use Group(s): SECTION 4:BUILDING HEIGHT AND AREA - - Existing Proposed No.of Floors/Stories(include basement levels)&Area Per Floor(sq.ft.) Total Area(sq.ft.)and Total Height(ft.) 1037 10 1037 10 _ SECTION 5:USE GROUP(Check as applicable) A: Assembly A-1 ❑ A-2❑ Nightclub ❑ A-3 ❑ A-4❑ A-5❑ 1 B: Business ❑ E: Educational ❑ F: Facto F-1 ❑ F2❑ H: Hi h Hazard H-1.❑ H-2❑ H-3 ❑ H-4❑ H-5❑ 1: Institutional I-1 ❑ I-2❑ I-3❑ 1-4❑ M: Mercantile W R: Residential R-1❑ R-2❑ R-3❑ R-4❑ S: Storage S-1 ❑ S-2❑ U: Utility❑ Special Use❑and please describe below: Special Use: SECTION 6:CONSTRUCTION TYPE(Check as applicable) IA ❑ IB ❑ IIA ❑ IIB ❑ 1 IIIA ❑ 1I11113 IV ❑ VA ❑ VBI� SECTION 7:SITE INFORMATION(refer to 780_CMR 111.0 for details on each item) - Permit Debris Removal: Perm Water Supply: Flood Zone Information: Sewage Disposal: Trench - Licensed Disposal Site❑ Public❑ Check if outside Flood Zone❑ Indicate municipal❑ A trench will not be p Private❑ or indentify Zone: or on site system❑ required❑or trench or specify: permit is enclosed❑ Railroad right-of-way: Hazards to Air Navigation: MA Historic Commission Review Process: Not Applicable IS Is Structure within airport approach area? Is their review completed? or Consent to Build enclosed❑ Yes❑ or No❑ Yes❑ No ❑ SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY Edition of Code: Use Group(s): Type of Construction: 56 Occupant Load per Floor: Does thebuilding contain an Sprinkler System?: Yes Special Stipulations: ��Nt "1V ( I7I (G9 SECTION 9: PROPERTY OWNER AUTHORIZATION e; Name and Address of Property Owner Walmart real Estate Business Trust 2001 SE 10th St Bentonville,AR 72712 Name(Print) No.and Street City/Town Zip Property Owner Contact Information: 479 -204 - 2702 Title Telephone No. (business) Telephone No. (cell) e-mail address If applicable,the property owner hereby authorizes Marie Vermillion 2809 Aiax Ave Suite 100 Rogers AR 72712 Name Street Address City/Town State - Zip to act on the property owner's behalf,in all matters relative to work authorized by this building permit application. SECTION 10:CONSTRUCTION CONTROL.(Please fill out Appendix 2). - If building is less.than 35,000 cu.ft.of enclosed space and/or not under_Construction Controlthen check here Of and skip Section 10.1 10.1 Registered Professional Res onsible.for Construction Control Name(Registrant) Telephone No. e-mail address Registration Number Street Address City/Town State Zip Discipline Expiration Date 10.2'General:Contractor TBD - - - Company Name d� S 3 FSS" Name of Person Responsible for Construction License No. and Type if Applicable '+ r( ST �21 0(aE-_�ra T tZ N A C Z 3Zy Street Address City/Town State Zip Telephone No. business Telephone No. cell e-mail address SECTION 11:WORKERS'COMPENSATION INSURANCE AFFIDAVIT' M.G.L.c.152.§ 25C 6 - - A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit. Is a signed Affidavit submitted with this a lication? Yes❑ No ❑ SECTION 12:CONSTRUCTION:COSTS AND PERMIT FEE Estimated Costs:(Labor Item and Materials) Total Construction Cost(from Item 6)=$ 139995 1.Building $ Building Permit Fee=Total Construction Cost x (Insert here 2.Electrical $ appropriate municipal factor)=$ 3.Plumbing $ 4.Mechanical (HVAC) $ Note:Minimum fee=$ 1540 (contact municipality) 5.Mechanical Other $ Enclose check payable to City of Salem Inspections 6.Total Cost $ 139,995 (contact municipality)and write check number here 8930 SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information contained in this application is true and accurate to_the bee5f of my knowledge and understanding. Marie Vermillion /� permit coordinator 479 -544 - 4601 09.18.15 Please print and sign name Title Telephone No. Date 2809 Ajax Ave Suite 100 Rogers AR 72712 Street Address City/Town State Zip Municipal Inspector to fill out this section upon application approval: Name Date Details Page 1 of 1 Toe Offida Website of the EcecuaN,3 O hce of P U,c Safety dnd Sccu:lty(EOPSS) Mass.Gov Home Stall Agoncieo ensee Details ull ame: A BOISVERT ender: er Name: dress: ddress 2: ity: Whitinsville State: MA ipcode: 01588 o nt : Ll 'ted tates nicense o: S- 5 License Type: Construction Supervisor Profession: Building Licenses Date of Last Renewal: 10/9/2015 Issue Date: Expiration Date: 1 0/2 812 0 1 6 License Status: Active Today's Date: 1/6/2016 Secondary License: Doing Business As: Status Chan e: - - , -Licelise Renew o PrereQuisEi Information No Discipline Information ocumen um Close Window ©2011 Commonwealth of Massachusetts Site Policies Contact Us http://elicense.chs.state.ma.us/Verification/Details.aspx?agency_id=1&license_id=274300& 1/6/2016 Appendix 1 For the demolition of structures the building permit applicant shall attest that utility and other service connections are properly addressed to ensure for public safety. Please fill in the information below and submit this appendix with the building permit application. The building permit applicant attests under the pains and penalties of perjury that the following is true and accurate. Property Location (Please indicate Block # and Lot# for locations for which a street address is not available) No. and Street City/Town Zip Name of Building(if applicable) For the above described property the following action was taken: Water Shut Off? Yes ❑ No ❑ Provider notified and Release obtained? Yes ❑ No ❑ Gas Shut Off? Yes ❑ No ❑ Provider notified and Release obtained? Yes ❑ No ❑ Electricity Shut Off? Yes ❑ No ❑ Provider notified and Release obtained? Yes ❑ No ❑ Yes ❑ No ❑ Provider notified and Release obtained? Yes ❑ No ❑ Other (if applicable) Yes ❑ No ❑ Provider notified and Release obtained? Yes ❑ No ❑ Other (if applicable) L h Appendix 2 Construction Documents are required for structures that must comply with 780 CMR 107. The checklist below is a compilation of the documents that may be required for this. The applicant shall fill out the checklist and provide the contact information of the registered professionals responsible for the documents. This appendix is to be submitted with the building permit application. Checklist for Construction Documents* Mark"x"where applicabIe No. Item Submitted Incomplete Not Required 1 Architectural 2 Foundation 3 Structural 4 Fire Suppression X 5 Fire Alarm(rnaV require repeaters) 6 HVAC 7 Electrical X 8 Plumbin include local connections X 9 Gas Natural,Propane,Medical or other 10 Surveyed Site Plan Utilities,Wetland,etc. 11 Specifications X 12 Structural Peer Review 13 Structural Tests&Inspections Program 14 Fire Protection Narrative Report 15 Existing Building Survey/Investi ation 16 Energy Conservation Report 17 Architectural Access Review 521 CMR 18 Workers Compensation Insurance 19 Hazardous Material Mitigation Documentation 20 Other(Specify) 21 Other(Specify) 22 Other(Specify) *Areas of Design or Construction for which plans are not complete at the time of application submittal must be identified herein.Work so identified must not be commenced until this application has been amended and the proposed construction document amendment has been approved by the authority having jurisdiction.Work started prior to approval may be subjected to triple the original permit fee. Registered Professional Contact Information 10506 William Hurley 479 -$7B--3651 Registration Number Name(Registrant) Telephone No. e-mail address Arch 08.31.16 2809 Ajax Ave, Suite 100 Rogers AR 72758 Street Address City/Town State Zip Discipline Expiration Date 49822 Thomas Stalcup 479- 878-3651 Registration Number Name(Registrant) Telephone No. e-mail address 2809 Aiax Ave Suite 100 Rogers AR 72758 Mech/Elec 06.30.16 Street Address City/Town State Zip Discipline Expiration Date Name(Registrant) Telephone No. e-mail address Registration Number Street Address Ci /Town State Zi Discipline Expiration Date 2 2809 Ajax Avenue Suite 100r F Rogers, Arkansas 72758, Phone: 479.635i 45 architecture +engineering DATE:09.18.15 JOB #: 15.0279.03.60.REIMB TO: City of Salem Inspectional Services RE: Walmart # 2640 120 Washington St., 3rd Floor VC OTP Submittal to AHJ Salem, MA 01970 450 Highland Ave Thomas J. St. Pierre - 1978.619.5640 Salem, MA 01970 We are sending you the following information on the above referenced project for your use. Please call if you have any questions. Thank you. COPIES DESCRIPTION 3 Sets Plans- CVR, VC1, VC2, MVC1, MVC2, EVC1, EVC2, EMI 1 Application 1 Check #8930 $ 1,540.00 If enclosures are not as noted, please notify us immediately. Signed, Marie Vermillion, pb2 permit coordinator pb2 architecture + engineering 479.878.3651 marie.vermillion@pb2ae.com XX/xx xc File Shipping 4 via: 2 day delivery pb2 a+e p.o. box 2076 rogers ar 72757 Massachusetts Department of public Safety Board of Building Regulations and Standards License: CS-085355" Construction Supervisor p;I IS EDWARD R BOISVE�RT Bt BORDER STREE _ �. WXITINSVILLE 119A / r n lit P-jZU CA— - Expiration: Commissioner 10/28/20 16